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About the series
As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.
H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.
Continuum of care is not fully connected until it's connected to patients who are actively engaged in their health. It's the end game in the "end-to-end" integration of care that the health care industry talks so much about. But unlike components of the integrated model that have been in development for a while — like health information exchange, electronic health records and even the medical home model — tools for patient engagement are mostly in the early figuring-out stage.
The American Hospital Association, for one, has figured out that "engaging users in health care is essential for transformation of the care system," and that "as health care evolves and user engagement matures, it creates opportunities to dramatically improve health care delivery." Those are introductory thoughts in its 2013 report, Engaging Health Care Users: A Framework for Healthy Individuals and Communities. The document also lays out more than a dozen cases in which patients are engaging with providers at the individual, organizational and community levels.
A new — and significant — technology driver is the set of criteria in the second stage of EHR meaningful-use targets dealing with patient engagement, including secure communication between doctor and patient, and timely ability of patients to view, download and transmit information from recent doctor visits or hospital stays. But the larger goal is to make ongoing healthy attitudes, rather than just medical issues, a care priority, says Paul Tang, M.D., who chairs the federal workgroup that framed the criteria for the Centers for Medicare and Medicaid Services last year.
Contrasting the traditional sick-care encounter, "in the new world you really want to be a partner with communities of people, so that's in health and in sickness," Tang says. For example, "people want to eat a healthy diet because they want to be healthy, not because they're treating their sickness." Individuals need "data, knowledge and tools" to understand their health and do something about it, says Tang who, as vice president and chief innovation and technology officer at Palo Alto Medical Foundation, is laying that approach over a huge base of engagement.
In a medical group of 1,000 physicians serving 800,000 patients in northern California, 76 percent of the adult patient population is signed up for Palo Alto's personal-health portal, including 71 percent of people in their 60s, 58 percent in their 70s, and 37 percent in their 80s, says Tang. Beyond access to their data, they get access to "people who are professionals at giving you personal advice," he says. Someone with diabetes who needs to keep blood-sugar levels under control "should be able to look up, 'What is an a1c, and what does it mean?' But you also should have access to people whose professional training can say, 'What does your a1c mean and what can you do about it?' "
Though interactive patient-provider portals typically are seen as the first line of engagement — and for meeting meaningful-use requirements — imaginative use of information technology can be both varied and basic.
For example, North Shore-LIJ Health System in metropolitan New York has developed a secure homegrown video-clip system based on the YouTube model to record patient sessions with their surgeon while diagnostic-image and other test results are explained, preserving all that visual and spoken knowledge for the patient to replay or send to family or other doctors [see sidebar].
At Miami Children's Hospital, staffers distribute wireless tablets to query parents as they wait for appointments, seizing the usually wasted time to gauge whether they're minding medication instructions, that they're aware of clinical trials for which a child is eligible, or that all the care interventions pertinent to a child's condition are up-to-date. Parents are then able to bring up issues with the doctor.
Palo Alto figured out a way to manage diabetes without relying on regular patient visits; instead, devising a system of checks on patient status using wireless remote monitoring tools that synced with a smartphone in the home and uploaded to the group's EHR. Combined with other tech tools, such as interactive visual displays of data against progress toward health goals in each patient's portal link, patients using these tools had significantly improved diabetes control and secondary improvement in cholesterol levels.
The way a diagnosis is explained to a patient for the first time is a key moment. That crucial interaction will impact how engaged a patient becomes in his or her treatment plan, so the language that clinicians use and the way it is delivered need to be both understandable and easily recalled, says David Langer, M.D., a brain surgeon who often delivers serious news. The moment of going over a CT scan and finding the right words to explain what it shows is now something a patient can rerun over and over, thanks to a service at the North Shore-LIJ System that captures the moment on video and reduces it to a 75-megabyte clip.
"Video is ubiquitous, it's understandable, it memorializes an event," Langer says. "All the data that are generated on the screen [showing high-definition diagnostic images] suddenly are compacted into a medical highlight reel that the patient can get at home." Langer described this method of patient engagement to a packed room at the annual Healthcare Information and Management Systems Society convention in New Orleans earlier this year.
In a poll of 30 patients who had downloaded their clip, 29 shared it with a friend or family member, and eight shared their video with another doctor. On a 5-point scale of benefit, the poll scored an average of 4.9. Langer says this speaks to the relevance of the information; hospitals and the Internet provide general information, but "you've taken the pamphlet [and] turned it into a video; you've taken the DICOM [standard image], and you've made it understandable."
So what does a wireless pedometer have to do with managing hypertension? Quite a bit, it turns out. As part of an overall health program, tracking walking activity both encourages and informs that activity, which is good for improving the health habits that go into staying medically stable, Tang says.
A clinical trial around hypertension control that concluded in March measured not just blood pressure and weight but also steps, "not because steps are directly controlling your blood pressure — it does have an indirect effect — but because steps are a measure of your activation and a measure of your health behavior," says Tang. Patients using a device called a Fitbit get results transmitted wirelessly to a receiver in the home and on to a computer application, where results and progress are graphed and displayed, ideally as motivation to keep it up or step it up.
"It becomes a tool for you to, in a sense, monitor your health behavior," he says. The pedometer provides access to data and tools. "You have to engage people by not just giving them numbers, not just by giving them advice, but by giving them something that can help them manage their own health."